Developing and Implementing
“Delirium Care Pathways”
Associate Professor Victoria Traynor
School of Nursing, Midwifery & Indigenous Health
and NSW/ ACT Dementia Training Study Centre,
University of Wollongong
&
Nicole Britten
Agedcare Services Emergency Team (ASET)
Wollongong Hospital,
Illawarra and Shoalhaven Local Health Network
Best Practice Delirium Care in Australia
• Department of Health & Ageing
– 2006: Publication of “Delirium Clinical
Practice Guidelines”
– 2008: University of Wollongong
commissioned to develop delirium care
pathways
– 2011: Publication of “Delirium Care
Pathways”
• CPG:
121 page document
• Low level awareness
that document exisits
• Stoke Pathway:
46 page document
• What can we do to
increase awareness
and use of pathway
documents?
“Delirium Care Pathways” Project Aims
•
Build on the “Clinical Practice
Guidelines for the Management of
Delirium in Older People”
Develop cross-setting “Delirium Care
Pathways” for
•
–
–
–
(i) community
(ii) acute
(iii) residential aged care facilities
Overall Project Design
• Deductively develop “Delirium Care Pathways”
• Range of stakeholders involved developing
content and format
– Practitioners
– Patients/ clients
– Carers
• Qualitative data collection and analysis
• Expert Advisory Group reviewed content and
format throughout project
• Trial of “Draft Delirium Care Pathways”
Three Stage Project
• Stage one
– Literature review
– Ethics approval from UoW and SESIAHS
– Draft “Delirium Care Pathways” Version1
• Stage two
– Focus groups and interviews
– Draft “Delirium Care Pathways” Version2
– Draft “Delirium Care Pathways” Version3
• Stage three
– Trial of Draft “Delirium Care Pathways” Version3
– “Delirium Care Pathways” Final Version
Stakeholder Involvement
State-wide and cross-setting representation
• Practitioner Interviews
–4
• Expert Interviews
–4
• Focus groups
– 7 (37 participants)
Summary of Themes
• Clinical Guidelines
• Relevance of Pathways
• Purpose of Pathways
• Content of Pathways: Assessment and
screening
• Patient journeys to reflect cross-setting
relevance of Pathways
• Publication and distribution of Pathways
Trial of “Delirium Care Pathways”
• 15 sites
–3 x community
–5 x acute (3 x ASETs and 4 x wards)
–5 x Residential Aged Care Facilities
(high and low care)
• 12 patients
Improving practice
• Knowledge translation
– Awareness, acceptance, application and adherence
• Diffusion process
– Rogers model
• Practice development
– Manley, McCormack, Titchen, Dewing and Walsh
– Critical social science and organisational culture
change
• The ‘Dementia Bridge Walk’
– Tom White, DCRC
Implementing “Delirium Care Pathways”
• Setting
– Community
– Acute
– Residential Aged Care Facilities
• Target audience
– Registered Nurses and Enrolled Nurses
– Medics including GPs
– Allied health practitioners
• Format
– Printed copy
– Poster version
– Internet web version with hyperlinks embedded
DELIRIUM CARE PATHWAYS Final Version6
Consider for use if aged over 65 years or 45 or older for Aboriginal or
Torres Straight Island Communities (ATSI)
Delirium may be a life threatening and potentially reversible condition
Preventative Strategies for Delirium
Has the patient/client been identified as potentially suffering from delirium?
No
Yes
• Cognitive function assessment tools */pg
3 or ensure appropriate referral is made
• Known risk factors for the development
of delirium pg 4
• Information from patient/client, carer,
GP, medical record or facility
assessments
• Delirium diagnostic tools or diagnosis by
Expert * /pg 7
1. Conduct baseline cognitive function assessments *
Does patient/client have a cognitive impairment?
No
Yes
2. Determine any changes in cognitive function
Has there been a recent change in cognitive function?
Yes
No
3. Assess for Delirium
Does patient have a confirmed diagnosis of delirium?
Yes
No
4. Consider subclinical delirium
Does patient/client have some symptoms of delirium?
Yes
No
Include in care plan
• Prevention pg 5
• Screen at regular intervals for change in
cognitive function pg 3
• Risk factor assessment and
management pg 4
• Involve Mental Health Team as relevant
Differential diagnosis (refer to Poole’s
Algorithm pg 6)
Adapt care plan
• Consider who is consenting to care
• Identify and address causes pg 8-10
• Manage symptoms pg 11
• Pharmacological management pg 12
• Provide supportive care pg 13
• Prevent complications pg 5
• Monitor resolution following facility
guidelines*
• Manage modifiable risk factors pg 4
• Educate patient and family, give facility
pamphlet or pg 14, consider use of
interpreter
• Refer to advanced care plan
5. Monitor and respond to any sudden changes in
cognitive function by repeating pathway
*People to use service/facility preferred diagnostic and assessment tools or other relevant material.
Adapted from: Clinical Epidemiology and Health Services Evaluation Unit 2006, Clinical Practice Guidelines for the Management of Delirium in Older People,
Victorian Government Department of Human Services, Melbourne, Victoria.
12
Case Study: Community
• 83 year old male known to ASET admitted to
emergency department with extreme acute
confusion. Family not coping with caring for
man due to his confused state. Yet again,
confusion due to a urinary tract infection
which would not have caused delirium if
treated sooner when first symptoms noted by
community care.
Community Outcome
• Delirium would not have resulted in a
emergency presentation because
community staff would have
provided some education for family
members about UTIs and delirium
and ensured anti-biotics prescribed
sooner.
Case Study: Acute
• 78 year old woman lives with family and
experiences some level of cognitive impairment
and family report a “confusion” which recently
increased. Came to emergency with shortness of
breath. Doctor reviewed, prescribed anti-biotics,
and recommended discharge. ASET fulfilled usual
role in “screening” all frail older people discharge.
Patient extremely acutely confused and on
questioning family patient normally only
disorientated to time.
Acute Outcome
• ASET immediately searched out
medic to discuss case. Medic took
on board recommendation by ASET
and patient admitted to medical
ward for further assessment.
Case Study: Residential Aged
Care Facilities
• 88 year old man who has a catheter and presents
to the emergency department because of
increased wandering and agitated behaviour
around care home. On presentation urinalysis
reveals a urinary tract infection which was not
identified by care home staff.
RACF Outcome
• It is common for some care homes to
not to undertake routine urinalysis of
residents with catheters. Admission
for 24 hours while intravenous
antibiotics have time to start working
and extreme acute confusion
diminished and care home able to
care for gentleman.
Implementation strategies
• Piggy back on ‘Essentials of Care’ project
• Management ‘buy-in’ for clinical staff
–
–
–
–
Complete facilitation skills sessions
Undertake audit
Implement practice development strategy
Recruit ‘delirium champions in ‘soft target’ clinical
area
• Bottom up implementation strategy to
improve practice
Implementation project: Audit
• 5 x ASETS in South East Sydney and
Illawarra and Shoalhaven Local
Health Networks
• 200 audits
• Presentation rate of delirium
• Screening rates for delirium
• Treatment rates for delirium
• Implementation timeframe
Conclusion
• Across setting “Delirium Care Pathways”
document now approved to accompany “Clinical
Guidelines”
• Deductively developed documentation informed
by experts and current practitioners
• User friendly “smart” documentation
• Documentation available Australia-wide for use in
late 2010
• Potential for use to an international audience
• Large scale implementation plan in SESIAHS
Aged Services Emergency Team in Spring 2010
References
•
KPMG (2008) Broken Hill Aged Care Project in the Greater Western Area Health
Service: Implementation report Sydney: NSW Health
•
Han L. McCusker J. Cole M. et al. (2001) Use of medications with anticholinergic effect
predicts clinical severity of delirium symptoms in older medical in-patients. Archives of
Internal Medicine 161(8):1099-105
•
Inouye, Sharon; van Dyck, Christopher; Alessi, Cahty; Balkin, Sharyl; Siegal, Alan &
Horwitz, Ralph (1990) Clarifying confusion: The confusion assessment method: A new
method for detecting delirium Annals Internal Medicine 113; 941-948
•
Karlsson I. (1999) Drugs that induce delirium. Dementia Geriatric Cogn Disord 10:412415
•
Aged Care Services, Liverpool Hospital (2004) Delirium in the Older Person Liverpool:
South Sydney & Western Area Health Service
•
Melbourne Health (2006) Clinical Practice Guidelines for the Management of Delirium in
Older People Melbourne: Victorian Government Department of Human Services
•
NHMRC (2003) When Does Quality Assurance in Health Care Require Independent
Ethical Approval? Canberra: NHMRC
•
NSW Health (2007) Guidelines for Ethics Submission Sydney: NSW Health
•
Poole, Julia & McMahon, Christine (2005) An evaluation of the response to Poole’s
Algorithm Education Programme by Aged Care Facility Staff Australian Journal of
Advanced Nursing 22(3); 15-20
•
Wilhelm, Kay & Brakespear, Michael (2007) Delirium Pathways Sydney: St Vincent’s
Hospital
Contact Details
Associate Professor Victoria Traynor
School of Nursing, Midwifery & Indigenous Health
NSW/ACT Dementia Training Study Centre
Building 41
University of Wollongong
Telephone: +61 (2) 4221 5213
Fax: +61 (2) 4221 4718
Web address:
http://www.uow.edu.au/nursing /health/nursing/
http://dementia.uow.edu.au